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If a clinician defers a decision to a CEC, hoping for a more expert answer, he may consider that the CEC embodies characteristics that enable them to make a more appropriate choice on an ethical issue, assuming an expertise that if it exists is very difficult to define, and may not in many cases exist. In the clinical area, the assumption of expertise, may lead to referral and deferral of a decision, as the implied expertise is often accompanied by an assumption of authority.

As Rasmussen (2011 p649) states:

“Expertise makes claims to authority plausible: Unless there is a special area of knowledge, or set of skills, over which some but not all may claim mastery, there is no reason to deem some but not all authorities”.

If CEC members cannot claim that they have the ability to get the decision ‘right’ more reliably than the clinician, by having no measure by which to prove, this, then the aim of the group should not be to seek this end.

Neither, can the group claim to hold perspectives that can be seen to be

representative of the clinical teams, and the patients and their families, due to the diverse nature of individuals in society. We live in a highly diverse and multi- cultural society in which decisions are made in the context of, cultural, religious, professional, societal norms and rules. Each individual is subject to their own unique set of influences which will impact upon the decisions they make in life. A small number of persons cannot confidently act as moral experts, able to identify what constitutes morally right action for another.

As Rasmussen (2011 p654) states:

“From within a pluralistic society, the idea that a single person, or even small team of people, can adequately serve as moral experts for all moral perspectives seems ludicrous”.

There will be expertise in the group that can be drawn upon to illuminate, clarify, challenge and confirm issues and perspectives however.

Moral authority and the clinical ethicist

It is easier to defend the position that CEC volunteers, with varying experience and knowledge of ethical theory, cannot claim greater moral expertise than the

clinician. The clinical ethicist, who is often part of the CEC, may find this

assumption more difficult to argue against due to their title and assumed high level of knowledge in ethics. Clinicians will see the clinical ethicist as an expert in his field, an expert in argumentation and debating, and akin to the senior medical consultant, they even share the same title. This notion of authority linked to

theoretical knowledge should be refuted by the ethicist in his role in the CEC. They should also reject the notion of moral authority through such ascribed expertise. Bioethicists are acknowledged for their theoretical expertise and this has been recognised as linked to authority at times. As Scofield (2008 p95) states:

“bioethics has come to be recognised as an authoritative field. Indeed, many would argue that the field has come of age. Increasingly, bioethicists are sought after for their expertise”.

In the case of the CEC, such expertise cannot be seen as conferring moral authority, particularly in the ethicist’s role as a CEC member. I have already mentioned that no member of the team can make claim to moral authority in a

difficult clinical case, except maybe the person with capacity making the decision. There are other reasons why moral authority by the CEC member, even if a trained ethicist, cannot be claimed. In an objective sense, an action may seem rational and reasonable. When the non-moral features of the case are considered such as culture, beliefs, religion, the clinician may make a different choice. This different choice may not at first seem to be the most rationally or objectively apparent, but taking into account the previously mentioned, cultural, social, religious needs, becomes the right one by nature of those influences.

The case of the Jehovah’s Witness family refusing blood products that could save the life of their child is an example.

This rejection of moral authority within the CEC does not mean that there is no benefit to case or issue review by such an interested group. A ‘fresh pair of eyes’ from a non-medical perspective, a willingness to question, challenge, compare cases and assist the clinician as they ensure all perspectives are heard within the case. Varying levels of expertise should be recognised and utilised to assist the clinician and the team. Moral authority is not an attribute that the CEC should seek to embody. Assumptions on moral authority should be dispelled at the outset and throughout any consultation for the reasons identified.

The confusion around the notion of ‘ethical expertise’ and how this translates into moral authority is reflected in the statement by Bishop et al (2010 p75) who state:

“Clinical Ethicists, according to Engelhardt, claim normative expertise in matters moral and at the same time deny moral authority in actual cases. This equivocation is fed by and contributes to the confused expectations for clinical ethics consultation”.

CECs can support the clinician with their consideration of a judgement on action, not by exercising their morally expert status and assuming moral authority for the decision, but by demonstrating by harnessing dialogue and assisting the clinician to translate this into action. Practice of ethical review through active and post-hoc cases assists the CEC to develop procedural skills, knowledge and attributes which can be taught to the clinicians using the group. This procedural and ethical competence is on a par with competence any reasonable clinician should and could seek to achieve, and which is enhanced by practice using the model in a variety of contexts. Members of Clinical Ethics Committees can demonstrate a reflective model within CEC debates that allows the dialogue about issues that arise, considering we all have a common-sense morality. The notion of common- sense morality is defined as “the set of moral maxims of which ordinary people have knowledge and of which they make use in their quotidian lives” (Archard 2011 p123). These maxims may be difficult to interpret at times, and people may require support to consider them, but they are maxims everyone has access to, and make judgements upon.

Performative expertise

The skill that the CEC membership can therefore develop, which places them in a unique position to offer support, is in the area of performative expertise. The CEC by the nature of being a group brought together by a common cause, to further the future of clinical ethics, can develop skills that support and enable themselves and other team members/clinicians to develop their own moral competence in decision making and moral judgement. Skills they can develop useful to assist them in this endeavour are; group facilitation, conflict management, demonstration of empathy, communication skills, and all the skills which allow them to provide the right

environment, for case discussion to happen and for learning to occur, which will inform the clinician and build his moral confidence. Weinstein (1993) discusses the difference between epistemic (cognitive) and performative (act) expertise, here the expertise to be pursued by the CEC should be that of performative expertise through the ASCS model, that I will discuss later, to enable them to assist the clinician with their issue/case concern by using an appropriate structured

questioning and facilitation technique to enable the clinician to make the decision for themselves.

The benefit of being non-expert in ethics is that there is no obligation on the part of the CEC to provide a recommendation on action, and there is no obligation on the part of the clinician to accept such a recommendation, in fact this would undermine the goal of the CEC working for the previously mentioned reasons. Even if an expert in morals or ethics were to be found who could argue clearly the rationale for his very plausible and logical solution to a dilemma (and I have identified that we have no way of measuring who is such a person), this still should not oblige the clinician to accept the judgement, as the most appropriate one, as Archard (2011 p120) states “acknowledged experts can and frequently do differ in their

judgments”.